HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Partnerships to Advance Cultural and Linguistic Competency

Within State Title V Programs

TAWARA GOODE: Good morning everyone. We're really pleased to be here and it's not such an effort for Wendy and myself who are right here in Washington, D.C. but we're so pleased. That Dr. Rogers decided to join us and fly all the way from Oregon and we are thrilled to have him here and to participate on this panel. Diana asked that I speak up, which is generally not anything you usually have to tell me to do but I am doing so this morning. What Wendy and I would like to present to you.

UNKNOWN SPEAKER: Is the mike on?

TAWARA GOODE: Is the mike on now? Okay, all right. Thank you. What Wendy and I will do this morning is to offer a conceptual framework for cultural linguistic competence; we're going to share that with you. We begin all of our presentations with those so that we're on the same page as it to relates to how we define these two terms. Then we're going to look at a technical assistance and constant teaching model that we use with two States and that is North Carolina and the great state of Oregon, and to share those experiences today. And with that said, we'll go ahead and get started.

We use a framework for cultural competence that was developed in 1989 by Terry Cross, Barbara Bazron, Karl Dennis and Mareasa Isaacs, and we're just going to go over this really very briefly. Something you are probably very much familiar with, but just want again to show you that we're on the same page. We really are defining cultural competence as requiring organizations having to have a very clearly defined and congruent set of values and principles; and that they demonstrate behaviors, attitudes, policies, structures and practices that will enable them to work effectively cross culturally. And we're looking at all of these ovals, behaviors, practices, policies, attitudes, and structures. We define culture really very broadly as indicated in this slide. We view it as an integrated pattern of human behavior that includes a myriad of things; not limited to the ones that you see here. Including communication, languages, relationships, practices, expected behaviors, customs. And that can be within a racial group, or ethnic group, religious group, a social group and/or political group and then there are other groups that are just too numerous to mention here.

We know that culture is transmitted from generation to generation, but yet we also know that culture is ever changing. And so this is a very broad definition of culture that we use and we are using the term culture as opposed to racial ethnicity because we view them as very different things. Competence as we use in this framework really looks at requiring values, attributes, knowledge, and a skill set to work effectively cross culturally. And in the literature you'll see lots of terms. Culturally effective, culturally appropriate, culturally relevant, culturally sensitive, culturally aware. Those terms all mean something different. When we look at this term competence, it really does mean being able to change behavior in the face of acquiring knowledge. So that means that just because I'm culturally aware doesn't make me change anything different in my practice. This really does speak to behavioral changes.

Quickly in terms of definition of linguistic competence, and my colleague Wendy and I created this definition. In a recent literature review we’ve been conducting for some work for the Commonwealth Fund, we find that the term is more prevalent in the literature, but it's not necessarily defined. So we crafted this definition and would like to share it with you this morning. We believe that linguistic competence is the capacity of an organization and its personnel to be able to communicate effectively, and to convey information in a manner that is easily understood to diverse audiences. Traditionally when we look at linguistic competences, it has been used in association with language access and in Title V. We've seen that a lot. We know that there are many people with communication needs within the health care, in our health care systems and our mental health care systems. And so we're looking at expanding that definition to include people who may speak a language other than English at home, people who may or may not be literate either in English or in their language of origin, and also individuals who may have disabilities that may have very distinct communication needs.

We need to be able to communicate effectively with these groups. We also know that linguistic competence really does require organizational and provider capacity to address the health literacy needs of individuals. And this is a new segment that we've added to this definition based on all of the work out of IOM and HRSA and other places that really is putting health literacy first and foremost. That we know that individuals may indeed be highly educated, may have I don't know, PhD in math, highly literate, however, may not understand simple health terms and concepts, which is really very important. So we wanted to acknowledge that. And lastly, organizations must have policies, structures, practices, procedures, and dedicated resources to support this capacity. In our work with Title V programs across the country we found, to some extent, that individuals have not necessarily been trained to work with interpreters for an example, and there has not always been adequate resources allocated. And so in this definition we're looking at all of those levels.

These are some simple examples of linguistic competence we've been able to document over the years. I'd like to maybe just bring, call your attention to, this one in particular. And this is looking at translation of legally binding documents. What's important to note is that there's been, I would say, more and more litigation around the whole issue of informed consent, and I think this is very important for us to consider. How do you know if you have informed consent if a person fundamentally does not understand what he or she is signing? And that we don't always have structures in place at that very intake level to explain the complexity of the forms that we're asking people to indeed sign. And so again, our definition of linguistic competence is all encompassing, and again looking at these strategies and approaches. I'm going to share up the mike now with Wendy Jones who is going to talk a little bit about family center care.

WENDY JONES: We had the pleasure earlier in the spring, to participate in a meeting that looked at the union of family center care and cultural and linguistic competence. And one of the things that was striking was that a lot of people felt that they were one in the same. If you're providing family center care then you're definitely being culturally and linguistically competent, or you're meeting those cultural and linguistic needs of the families that you're serving. And the other side was also true; that there was a belief that if you were providing culturally and linguistically appropriate services, then they should be family centered. So one of the things that we do always at the National Center for Cultural Competence, and whatever our activities are including in our advisory committee for the Children and Youth with Special Healthcare Needs Project, I'll be specific. Is to end others, is to other advisory committees, is to include family members. Recognizing that the wealth of experience and expertise that they bring to the table, we need it greatly to help us, to inform us, to guide us, and also sort of like a reciprocal situation. We learn from them, they learn from us, and hopefully strengthening the partnership or the collaborative relationship. So we're offering this definition of family center care that's out in being promoted just to underscore that. So I think the key things from this definition is that we're looking at enhancing or increasing, assuring the well being of Children with Special Healthcare Needs and their families but also all children. And this is through this family professional partnership and that we're hoping to honor the family strengths, traditions, culture, language, I'm putting that in it's not there but I'm putting it in, and also the expertise that each individual that's in this partnership brings to the table.

And these accompany that definition that MCHB is circulating, these principles of family center care. That again, families and professionals would work together in the best interest of the child and family. That everyone respects the skills and expertise brought to the table to the relationship. That trust is fundamental, can't move forward without that, can't establish a partnership without that. And also that it happens over time. Something that we're stressing all the time. That I'm not going to see you on day one an all of a sudden I trust you and I’m going to tell you all of my information, or all of my needs, or all of my preferences. That is something that's established over time. And that communication and information sharing needs to always be open and objective. Again, I'll interject that time piece in there, and that these too, families and the other entity that they're working with have to be partners in all decision making. And that negotiation is key and that it always has to be an option.

TAWARA GOODE: Again I'd like to emphasize clearly the role of cultural and linguistic competence in terms of this framework and again looking at family center care is clearly being included within that framework. And the evidence based on what we are seeing as it relates to the impact. And so as we think about addressing cultural and linguistic competency within our respective programs we know that there is literature that clearly, clearly justifies the quality and effectiveness of care. That there is an increase or improvement in that area. The literature also documents outcomes, health outcomes and well being, again within various groups within the literature, clearly increasing that. That there's increase in-patient and provider satisfaction, and also the notion of shared power between healthcare, mental healthcare service providers and seeing a definite increase. Having this, I think it really is very important, because we frequently hear there is no evidence. And we hear that a lot and that people continue to repeat it, and it almost gets to be like a truth because people hear it so much. There is clear and convincing evidence, it may not be voluminous. If we look at the resources that we've just really started to put in this, especially with the passage of Health Disparities Act of 1998, we're seeing more resources devoted to this. But there is clear convincing evidence and is very important as you continue to engage in services and supports and other interventions within your state that you're well aware of this evidence and what the implications are.

We also note that there is a direct correlation in terms of decrease in health and mental health disparities when cultural and linguistic competency approaches are indeed used. This is not to say cultural and linguistic competency is the sole panacea for addressing disparities, it clearly is not. There's a complex array of factors that contribute to disparities. It is one in a number of tools that can indeed be effective. It also looks at decreasing the disproportionate burden of disease and mortality, the social and resource inequities, and things that we've clearly been talking about the last two days at this meeting. And also there's clear evidence that speaks to the cost of care. Reducing the cost of care. And we see this particularly in areas regarding language access. So very quickly in terms of looking at a framework for addressing racial and ethnic disparities and geographic disparities, we'd like to look at many things that should indeed be linked, and looking at partnerships to assure that these things are linked. We view cultural competence, linguistic competence, and community engagement, family center, patient center care, health literacy, and partnerships between patients and health professionals. All of these need to clearly work together within our systems in order for us to have any true impact on reducing racial and ethnic disparities.

As we think about our approach to providing technical assistance and consultation, and again we've been very privileged to work with Title V programs and other MCHB funded programs for the past now ten, going on eleven years. We have learned in our approaches and things that would be very important for us to follow and that is to establish guiding principles for ourselves to look at in terms of division of technical assistance. One of the things we clearly know and the framework model for cultural and linguistic competence does indeed support this, is no one size fits all TA approach. That we really looked at tailoring our approaches to the social, cultural, and environmental context of the state, the program, or organization, and this is really very key. And often times we'll get TA a request to come in that they, someone may call in and just want to know what is your curriculum, what do you do for this population? We usually spend time talking with them in great detail to find out what are the unique issues that are going on within their environment. Because it's very important that we be able to address those if the consultation and technical assistance will indeed be, not just effective, but well used and meaningful when we're no longer there. We also look at making maximum use of funding and leveraging resources, in particular.

So that while we receive funding from the Children and Youth with Special Healthcare Needs division within Maternal and Child Health, we also receive other sources of funding from MCHB but also from SAMSA. How can we use these resources to provide more seamless approach to our technical assistance? Families don't neatly have their mental health things carved here, their health things carved here, Children with Special Healthcare Needs carved over here, and we need to be able to look at that, and I think that our products reflect that nicely. So that while we had funds from the Bureau of Primary Healthcare to develop a policy brief series, it's been very well received. And the primary focus and funding was for primary care and also for community health centers. We were able to craft those policy briefs, the policy brief series, in a way which they spoke to multiple audiences. And I think that is really very key in terms of, in this time of very scarce resources and perhaps even more scarce in the years to come. How can we maximize and leverage those funding.

And lastly, I'm looking at an inclusive process that embraces multiple state holders. And that's what we will share today. So if we're providing consultation within a state and it may be funding from the Children and Youth with Special Healthcare Needs Program, how can we involve other partners within that community that will be able to benefit this, because they're part of the whole system of care that we see for children and their families.

WENDY JONES: One of the things that in terms of the Children and Youth with Special Healthcare Needs project in order to figure out how it is that we're going to be able to tailor some of the requests or tailor our approach or our response to some of the requests that we get is to take a look at Block Grant information. So I always have the pleasure of doing that. Looking at the background information, but I’m always specifically looking at what states are asking for in terms of cultural competence, very infrequently see things specifically relating to linguistic competence. I think that folks have a way of looking at it as one ball of wax, the cultural and the language piece together. But when you're looking at those possible guidelines or federal mandates that really have, carry some weight and that can be, are enforceable, it's really around language so for the purposes of today I'm splitting them. When I looked at the Block Grant what I saw was that states were asking for, when it relates to cultural and linguistic competence, ways of monitoring or tracking the way that they are responding to or preparing to respond to the performance measure around cultural competence. And that they were asking or seeking assistance in that. That they were also looking for ways to improve the way that they collect racial and ethnic data and to be able to use that to address issues related to health disparities as they're experiencing them or seeing them in the populations that they’re serving. And also a more interest in looking at ways of connecting cultural and linguistic competence organizational self-assessment. So in other words, looking at their organization, and looking at it from measures around cultural and linguistic competence and applying it to how they do business with families, and then also looking at how to better develop policy as it relates again to cultural competence and linguistic competence.

So we also, saw some other issues around designing surveys. If Department of Health or Children with Special Healthcare Needs Program were looking at using a survey and maybe not ones that are available, not necessarily meeting the needs of a health department. Hearing this all the time, that the surveys that are available that look at cultural linguistic competence are not sort of large enough or broad enough to cover all the departments that exist within a health department. That they are asking for assistance in designing these kinds of surveys and also lots of requests for training for staff. Particularly around front line staff and also around policy and how do you incorporate specifically cultural and linguistic competence into policy around staff, around not only training, but also recruitment and retention, performance evaluation for staff and those types of things. Others are asking for assistance in developing cultural competence plans to help them really point out, look at what the results of their needs assessment say, and look at what they project, the projections for their communities. And try to map out what steps that they should take in order to improve what they are doing. And then also how to network with states that are already being successful, are a little further ahead with them, and for us to help with those linkages. And then often asking for ethnic or culture specific strategies for working with different populations.

Okay, so then in the course of my regular duty, we conducted a director’s query. Some of you here might have participated in this, but it was really looking at the extent to which directors of Children and Youth with Special Healthcare Needs Programs were really implementing, whether they were in planning, implementing, or not quite there yet around cultural and linguistic competence. And so this is selected results of the query. Which was really that folks are looking for promising practices. What are other people doing, what's been successful, and how can I replicate that in my community. Looking at again, same as what was said in the Block Grants, but this is a select population. Because while we did offer the opportunity for every Children with Special Healthcare Needs director in the states and territories to participate. Understandably the first go around, not everyone did. The second go round a larger group, so maybe we had 29 the first time and 23 the second time. I think that's pretty good. But it was a period, 2003 to the end of 2004 for folks to be able to do that and for a range of reasons. But again looking at developing cultural competence plans, and looking again at helping with this evaluation around distinct or different racial and ethnic data. How to use it, how to apply it, how to even include it in, when they're planning for activities based on the needs assessment. And then also looking at culturally competent and evidence based practices to address health disparities and one of the major things that we often hear is looking at confronting attitudinal barriers. So if the person somewhere at the top is interested in cultural linguistic competence and then having to deal with the mid-range folk and then also the front level folk. Everyone is not always at the same time ready to take on this journey or to begin this journey. And so really asking for assistance, how do you work that, how do you juggle it, and how do you work towards moving it, changing it?

TAWARA GOODE: As we indicated earlier we're looking at, looking our technical assistance approach again across programs and that was illustrated very nicely and in North Carolina and also Oregon. In 2002 we did a query from the Division of Research Training and Education looking at their grantees and in particular looking at their leadership interdisciplinary programs to really look at the extent to which curricula incorporated cultural and linguistic competency. Also looking at faculty development in a number of other specific arenas. And what we really found out is that the majority respondents regarding the extent to which curricula incorporated cultural and linguistic competence varied, and that faculty development, the supported acquisition of knowledge and skills and cultural and linguistic competence also varied significantly within the group of respondents.

These are some of the things that indeed the programs indicated as priority needs. That they really wanted more in the area of cultural and linguistic competent curricula. But and also support programs and technical assistance to help them integrate this better overall. Also strategies to assist with recruitment and retention of culturally diverse faculty, students, and work force. This was another priority need and I do want you to note that this was conducted in 2002 so that we see that's there's been significant progress in programs since that time and we're very pleased to see that. This is very consistent and we saw this in a Title V survey, and we also see it in the work that we do in Children’s Mental Health as support to address attitudinal barriers and resistance, this particular among faculty and within departments. In some of the information that we received that people still do not view this as legitimate area of study. That it's still fluff, that their quote is there is no hard science to back it up and so people are indeed encountering those barriers. Some people are encountering even other barriers that have their roots in bias and discrimination, and shared those with us in terms of the query. Clearly looking at, could be some very biased perceptions of immigrants, there disproportionate use of scarce resources. Lots of things are happening and I don't think that we should be surprised that our public health system would be different than some of the attitudes we see in general society. We would be naive to think otherwise.

We also had the privilege last year of working with a work group from DRTE and the group that we worked with again looked at this whole area of curricula enhancement and faculty development and these are some of the things that came out of that. And again it was increasing diversity in the current and future healthcare work force, which is a clear goal within the division. Leaderships and champions credibility to advocate for LEAH and change in academic institutions. One of the things that we saw a lot is that there, big difference was when there was a champion. When there was someone within a division or department and particularly someone that was higher up in the food chain, that this was very very significant in terms of promoting cultural and linguistic competency. Also looking at, that cultural and linguistic competency will be more fully integrated into curricula. Sometimes what we see is that there was a course, perhaps a series of lectures, which is one way of looking at it. Another way is to look at what is the relevance to cultural and linguistic competence throughout curricula. Meaning that it's integrated so people do not always think of it as an add on or expendable. And lastly looking at professional development to an increased capacity to partner with families and the community and to look at those individuals in the role of expert which can be very challenging within university settings. One there is hierarchy in a great degree of emphasis placed on what you' degree would be.

So these were again some of the strategies and approaches and things that we've learned and we've given you this as a backdrop to look at what our experiences were both in North Carolina and in Oregon. Unfortunately Carol Chant from North Carolina could not be here, Wendy Jones and I will be able to share some of the outcomes from that but we want to now pass this over so we can hear from the great state of Oregon.